18/01/2022
Too long a road for PCI!!
The recently published now published in NEJM has yet again established the superiority of CABG over percutaneous intervention (PCI) even after ascertainment of physiological significance of coronary lesions using fractional flow reserve (FFR). The results show that FFR-guided PCI failed to meet the non-inferiority margin for 1 year MACCE outcomes when compared to CABG in patients with triple vessel disease.
What’s FFR? This is a measure of the pressure gradient across a coronary lesion and have shown better out-comes when PCI is guided by FFR than when it is guided by “angiography alone” as shown by previous FAME trials.
In this multicenter, international, noninferiority trial, the investigators randomly assigned 1500 patients with triple vessel diasease to CABG or FFR-guided PCI. The primary end point was the 1-year occurrence of a major adverse cardiac or cerebrovascular event (i.e., death from any cause, myocardial infarction, stroke, or repeat revascularization). The trial participants were relatively healthy, with a mean age of 65 years and a mean body-mass index of 29. Diabetes was present in 29% of the patients, and only a minority had an ejection fraction of less than 50%. The complexity of coronary disease was relatively high.
The 1-year incidence of the composite primary end point was 10.6% among patients randomly assigned to undergo FFR-guided PCI and 6.9% among those assigned to undergo CABG.
Results: Mortality was 1.6% in the PCI group and 0.9% in the CABG group, and repeat revascularization occurred in 5.9% of the patients in the PCI group and 3.9% in the CABG group.
How do we incorporate this information into practice?
1. First, the totality of the data to date supports CABG as the standard of care for patients with stable multivessel coronary disease when the overall surgical risk is not high, when the complexity and burden of angiographic disease is high, and when diabetes is present.
2. Second, although the use of FFR may improve outcomes in patients undergoing PCI, FFR-guided PCI does not result in outcomes as good as those of CABG in patients with angiographically defined multivessel coronary disease.
Take Home Message: The FAME 3 trial bolsters the role of CABG as the benchmark for patients with multivessel coronary disease. However, a multidisciplinary approach and shared decision making may remain fundamental to the management of multivessel coronary disease in our daily practices.
Source: NEJM:
1. DOI: 10.1056/NEJMoa2112299
2. DOI: 10.1056/NEJMe2117325
